Revision with plates of humeral nonunions secondary to failed intramedullary nailing

Purpose

The objective of this study was to evaluate the results achieved after revision with plates of humeral nonunions secondary to failed intramedullary nailing.

Methods

We retrospectively evaluated 32 patients with humeral nonunions secondary to failed intramedullary nailing, treated by internal fixation with plates between 1998 and 2012. Nonunions were diaphyseal in 19 cases, they were located in the proximal humeral metaphysis in nine cases, and in the distal humeral metaphysis in four cases. There were 11 atrophic nonunions and 21 oligotrophic nonunions. Initial treatment was performed with static locked nails in 12 cases, nails with expansive locking systems in 11 cases, and using thin elastic nails in nine cases. The nails were placed antegrade in 18 cases and retrograde in 14 cases. Time between initial surgery and revision surgery averaged 14.5 months. In seven diaphyseal nonunions, the intramedullary nail was left in-situ. Bone graft was added in 25 cases.

Results

Follow-up averaged 35 months. Union was achieved in all cases, after an average of 3.8 months. Disabilities of the Arm, Shoulder and Hand (DASH) score at last follow-up averaged 14 points, and Constant’s score averaged 82 points. The analogue scale of pain averaged 0.8 points. Out of seven patients with radial nerve compromise, six recovered completely and one needed tendon transfers.

Conclusions

Revision with plates after failed intramedullary humeral nailing achieved union and good predictable objective and subjective results in all cases. Adequate implant selection and meticulous surgical technique are necessary to achieve successful osteosynthesis and bony union.     

Minimal-invasive Plattenosteosynthese proximaler Humerusschaftfrakturen mittels langer PHILOS-Platte

Objective

Closed reduction and minimally invasive stabilization of proximal humeral shaft fractures with long PHILOS plates. The presented technique enables stable extramedullary fixation of the fractures without affecting surrounding nerves.

Indications

Proximal humeral shaft fractures that may not be fixed by intramedullary nailing because of a narrow, deformed or occupied intramedullary canal or because of open growth plates.

Contraindications

Fractures that may not be reduced adequately by traction or with percutaneous techniques. Furthermore, fractures with delayed or nonunion and pseudarthrosis should not be treated with this technique.

Surgical technique

An anterolateral delta split approach is used to create an epiperiosteal tunnel along the humeral shaft from proximally to distally. A second incision is made distally at the lateral border of the biceps muscle. The brachialis muscle is dissected longitudinally. The PHILOS plate is twisted so that the proximal part of the plate can be placed laterally and the distal part anterolaterally at the humeral shaft. The plate is inserted into the epiperiostal tunnel and fixed with percutaneous screws.

Postoperative management

The arm is immobilized in a Gilchrest bandage until wounds are healed. Active-assisted physiotherapeutic mobilization without loading starts on the first postoperative day. Active mobilization starts 8–12 weeks postoperatively. In cases of soft tissue irritation the PHILOS plate may be removed after 1 year.

Results

Between 2005 and 2011 a total of 16 patients (8 women and 8 men) were treated with the presented technique. The patients mean age was 61 years. According to the AO classification, five fractures were classified as type A, eight as type B and three fractures as type C. All patients had clinical and radiological follow-up examinations after a mean of 24 months (12–38 months). All fractures showed complete bony consolidation at the final follow-up. The mean Constant-Murley score was 81 points representing 84% of the Constant-Murley score of the healthy contralateral shoulder. The average DASH score was 33 points and the mean SF36 was 85 points.     

Dynamic compression plating versus locked intramedullary nailing for humeral shaft fractures: a meta-analysis of RCTs and nonrandomized studies

Purpose

There is no consensus regarding treatment of humeral shaft fracture. In this meta-analysis, we pooled studies to compare dynamic compression plate with locked intramedullary nail for this injury.

Methods

PubMed, MEDLINE, and Embase databases were searched for relevant studies published between January 1995 and July 2012. Evaluated endpoints were method-related complications and revision. Study quality was assessed, and meta-analyses were analyzed using the Cochrane Collaboration’s REVMAN 5.0 software.

Results

Fourteen randomized controlled (RCTs) and nonrandomized studies with 727 patients were analyzed. There was a significantly higher risk of total method-related complications and shoulder impairment resulting from locked intramedullary nailing compared with dynamic compression plating. Plating was significantly associated with a higher risk of infection and postoperative nerve palsy. There was no significant difference with respect to nonunion and revision rate.

Conclusions

Nailing may cause more method-related complications and shoulder impartment than plating, although it may lead to a lower risk of infection and postoperative nerve palsy. In the future, more high-quality RCTs are required to enhance these conclusions.     

Humeral shaft non-union after intramedullary nailing

Background

The humerus shaft is one of the sites with the largest probability of developing pseudoarthrosis after fracture. We present the results of nine patients with atrophic pseudoarthrosis of humeral shaft treated with angular stability plate associated with allograft and platelet-rich plasma (PRP), after a first treatment with intramedullary nail to correct the fracture.

Material and Methods

From January 2012 to December 2014, nine patients were treated for atrophic pseudoarthrosis (PSA) of humeral shaft treated previously using intramedullary nail; seven humeral diaphysis fractures were located in the middle–proximal third and two in the middle third. In one case, a reverse shoulder prosthesis implant was associated to treat a co-existent rotator cuff massive lesion. The mean time between injury and treatment of non-union was 32 weeks (min 16–max 180); all patients were evaluated with Constant, DASH and UCLA score.

Results

At the final follow-up (23.7 months), the mean Dash score was 22.25 pt, the Constant score was 64 pt, and the UCLA score value was 27 pt. The average pain value was 2 for the arm interested and 0 into PSA focus. Radiographic healing was obtained at 7 months.

Conclusions

The humeral shaft non-union is an invalidating problem which affects the daily living. Our treatment with plate, cortical bone graft, and PRP can build a high-stability structure that can help healing and graft integration.

     

Augmentative locking compression plate fixation for the management of long bone nonunion after intramedullary nailing

Objective

Intramedullary nailing is widely used in the treatment of long bone fractures. But some patients suffer from nonunion after receiving intramedullary nailing. This paper investigates the methods and effects of locking compression plate (LCP) in the treatment of long bone nonunion after intramedullary nailing.

Methods

A total of 6 patients (4 males, 2 females) with long bone nonunion were enrolled. All these patients had previously undergone intramedullary nailing for fractures of long bones (4 femurs, 2 tibiae). The average time from injury to LCP treatment was 12.2?months. The locking compression plate was applied over the intramedullary nail, and unicortical purchase achieved with locking head screws due to underlying nails. Autologous bone grafting was done in all cases.

Results

Six patients were followed up for 12–20?months (mean 14.2?months). X-ray imaging showed bone callus at the broken ends of the fracture at 3–7 (mean 4.5)?months after surgery. All patients did not have any complications such as infection, breaking or loosening of the LCPs.

Conclusion

LCP can be used for the treatment of long bone nonunion after intramedullary nailing for its convenience, minimal invasion and curative effect.     

Submuscular double bridge plating for complex distal fractures of the humerus: an alternative,safe, and efficient treatment method

Purpose

The aim of our study is to show the functional outcomes and complication rates of humeral complex fractures in adults, using osteosynthesis with two bridging orthogonal submuscular plates.

Methods

The study consists of a prospective case series of 13 patients with isolated humeral complex fractures treated with two bridging orthogonal submuscular plates. Functional assessment was performed using disabilities of the arm, shoulder, and hand (DASH) score with 30 items. The age ranged from 22 to 68 years, with a mean age of 39 years. Functional assessment with DASH score was performed at the twelfth postoperative week.

Results

All patients presented fracture healing in the fourth postoperative month. Of the 13 patients, five (38%) had a DASH score of zero (best function possible). One patient developed neuropraxis and presented with a score of 100 (worst possible). One case developed superficial infection, which was treated with oral antibiotics and local debridement.

Conclusions

This study demonstrated satisfactory functional outcome in patients with distal-third diaphyseal humeral complex fractures treated with two locked submuscular plates. The authors consider it as a safe method and an efficient alternative, especially in younger patients who require early functional recovery.

     

Complications of locked nailing in humeral shaft fractures

BACKGROUND: The purpose of this study was to investigate the complications of humeral locked nailing. METHODS: Between 1994 and 2000, 161 humeral shaft fractures (98 acute fractures and 63 delayed unions or nonunions) in 159 patients treated with humeral locked nails were followed up for an average of 25.4 months. There were 89 men and 70 women, with an average age of 53.5 years. Acute fractures included 68 closed, 18 type I, 8 type II, 3 type IIIA, and 1 type IIIB open fractures. Thirty-six nonunions had previous operations. In general, acute fractures were treated with closed nailing and nonunions were treated with open nailing with bone grafting. Since 1998, interfragmentary wiring has been added in nonunions to compress the fracture. RESULTS: In total, 30 patients had 31 significant complications. Nine of them were persistent nonunions, six from acute fractures and three from nonunions. Fracture gap was associated with a significantly higher risk of nonunion. The risk of operative comminution was significantly higher in retrograde nailing, and operative comminution resulted in a significantly higher risk of nonunion. Seven of the nine nonunions underwent revisional nailing and achieved eventual union. Removal of the protruded screws was performed in two cases. Other complications included shoulder impairment, elbow impairment, angular malunion, and post-nailing radial nerve palsy. CONCLUSION: Many complications of humeral locked nailing can be prevented by improving the implant design or surgical techniques. The patients with persistent nonunion can be reliably treated by revisional nailing and bone grafting.     

Reamed intramedullary nailing of diaphyseal tibial fractures: comparison of compression and non-compression nailing

Background

Modern intramedullary implants provide the option to perform compression at the fracture gap in long bone fractures via a compression screw mechanism. The aim of this study was to assess if the application of interfragmentary compression in the intramedullary nailing of tibia fractures could increase the union rate and speed of fracture healing.

Methods

Sixty-three patients who suffered from an AO-type 42-A3 or 42-B2 fracture that was treated by reamed intramedullary nailing between 2003 and 2008 were included in this retrospective study. Twenty-five patients were treated with dynamic interlocking without compression while 38 were treated with compression nailing. The compression load of the dynamic proximal screw was calculated by postoperative X-ray and radiographs taken four weeks after operation. Healing was assessed by radiological evaluation until the completion of bony healing or the disappearance of clinical symptoms. Nonunion was defined as the absence of radiological union and the persistence of clinical symptoms after six months.

Results

Postoperative compression was applied at a mean load of 1,852 N, and 980 N remained after four weeks. In the compression group, 19 open and 19 closed fractures occurred. In the non-compression group, 25 patients were included (14 closed and 11 open cases). Active compression decreased healing time significantly. Nonunion occurred in one compression patient and three non-compression patients.

Conclusion

The results show that additional compression of the fracture gap can improve healing outcome in simple transverse tibial shaft fractures treated with reamed nailing.     

Effectiveness of exchange nailing and augmentation plating for femoral shaft nonunion after nailing

Purpose

We assessed indications and outcomes of exchange nailing and augmentation plating for femoral shaft nonunion following femoral nail failure.

Methods

We retrospectively reviewed the records of 21 consecutive patients with femoral shaft nonunion treated with femoral nailing from August 2008 to June 2013. Nonunion cases with infection were excluded from this study. The study population consisted of nine men and 12 women, with an average age of 40 (range 21–61) years. All patients received internal fixation using exchange nailing and an augment plate coupled with decortication and bone graft.

Results

All patients in our study obtained osseous union with a mean time of six (range four to12) months. Mean operation time was three hours (range two to five hours), and mean blood loss was 800 ml (range 500–950 ml). There were no postoperative complications. At the last follow-up, all patients could flex their knees > 110°.

Conclusions

Exchange nailing and augment plating coupled with decortication and bone graft is an effective treatment option for femoral shaft nonunion and has more indications and higher union rate than the popular exchange nailing treatment.     

Komprimierte Marknagelung bei Oberarmschaftfrakturen

Since there is low fragment impaction in the case of transverse and short oblique fractures of the humerus, these involve an especially high risk of nonunion. The body weight exerts hardly any axial load on the human humerus, which in daily life is exposed much more to tension and rotational forces, requiring a high stabilization potency. This can be achieved by intramedullary nailing; interfragmentary compression, if appropriate, can augment its effects. A special compression device shifts the dynamic bolt at the nail base together with its bone fragment in the direction of the fracture gap, bringing about fragment adaptation followed by fragment compression and locking of the bolt. The result is then consolidated by means of an additional, static, bolt. Biomechanical studies have shown significantly higher stiffness values for compressed intramedullary nailing than for conventional nailing in cadaver humeri. Clinical results in 21 cases of compression nailing of the humeral shaft show complete bone healing in a median of 3.4 months with no necessity for revision surgery. There were no complications in these patients. In transverse fractures of the humeral shaft the use of interlocking nails with interfragmentary compression yields greater stability and thus a higher probability of undisturbed and fast bony healing.     

Mid-term results of internal fixation of proximal humeral fractures with the Philos plate

Objective

To report our experience from the use of the Philos^® plate for the treatment of three- and four-part proximal humeral fractures and to investigate factors influencing the final outcome.

Materials and methods

Between April 2005 and September 2007, 29 Philos plates were implanted in 17 women and 12 men, with a mean age of 62.3 years (range: 28–80 years). Positioning of the plate was performed under fluoroscopic control, through a deltopectoral approach and with the patient in the beach chair position. 27 patients were available for follow-up (mean: 17.9 months; range: 12–39). Follow-up included plain shoulder radiographs and functional assessment with Constant–Murley score.

Results

Healing of the fracture occurred uneventfully within 6 months. In three patients, humeral head collapsed due to aseptic necrosis after fracture healing and the plate had to be removed in two cases. In one patient, fracture healing occurred in >10° varus displacement. The clinical result according to the Constant–Murley score was 86 points (range: 58–112).

Conclusions

Internal fixation with the Philos plate seems to be a reliable option in the operative treatment of upper end humeral fractures, especially in osteoporotic bone. It allows secure fracture fixation and quick shoulder mobilisation, while quick and uneventful fracture healing and very satisfactory clinical results are achieved.     

Internal fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail: A prospective study

Background:

The indications for surgical management of fractures of the shaft of the humerus are clear, but selecting the right implant for internal fixation of humeral fractures has been a dilemma.

Materials and Methods:

Thirty-six patients (mean age 40.53 years) with fractures of the shaft of the humerus were followed for 12 to 24 months in a prospective study. Eighteen patients each underwent open reduction and internal fixation with compression plating and ante grade interlock nailing. Clinical and radiographic outcome measures included fracture healing, shoulder and elbow functions, need for additional procedures and any complication such as infection and recovery of radial nerve palsy. The results were analyzed statistically using the SPSS 11.5 software, with parametric and nonparametric tests.

Results:

Nine of the fractures treated with compression plating and seven of those treated with interlock nailing achieved union within six months. Though there was no significant difference in union time between the treatment groups, patients operated with interlock nailing underwent more number of secondary bone grafting procedures to obtain union (six against two). There were 12 patients (66.6%) with excellent and good results in the plating group compared to four patients (25%) in the nailing group. Interlock nailing was associated with significant reduction in shoulder function (P=0.03) and in overall results (P=0.02).

Conclusion:

Though there was no significant difference between plating or nailing in terms of time to union, compression plating is the preferred method in the majority of fractures of the shaft of the humerus with better preservation of joint function and lesser need for secondary bone grafting for union.     

Ergebnisse der multidirektional-winkelstabilen Versorgung distaler Humerusfrakturen

Background

The treatment of patients with distal humeral fractures and reduced bone quality or complex fracture patterns is still complicated. Using angular stable implants should lead to better functional results.

Objective

The clinical and functional results were analyzed as well as the complications after treatment of patients with distal humeral fractures using angular stable plate osteosynthesis.

Material and methods

A questionnaire was sent to patients treated in our hospital for distal humeral fractures and they were invited for a follow-up examination. We investigated the DASH (Disability of the Arm, Shoulder and Head) score, Mayo Elbow Performance Score (MEPS) and EQ-5D-3?L for evaluation of functional results, as well as the VAS (“visuelle Analogskala”) score for evaluation of pain. Using radiographs the fracture patterns were classified and interpreted for complications.

Results

A total of 28 patients returned the questionnaire after a minimum of 6 months following the operation and 10 attended a follow-up examination in our clinic. The DASH score was 38.40 and the MEPS 72.31. The results for 15 patients were good to excellent. The EQ-5D-3?L was 0.790 and the VAS 2.76. We found a significant correlation between the DASH score and patient age (p = 0.028), as well as an inverse correlation of the DASH score and the EQ-5D-3?L (p < 0.001). The complication rate was 53.6%. The three biggest groups of complications were neuronal complications, healing disorders and problems with the osteosynthesis material.

Discussion

The treatment results showing that unsatisfactory results are possible even if angular stable plates are used. An inferior functional result as assessed by the DASH score reduces the quality of life measured by EQ-5D-3?L. A follow-up after 6 months appears to be sufficient to assess the outcome after complicated distal humeral fractures.

     

Angle stable interlocking screws improve construct stability of intramedullary nailing of distal tibia fractures: A biomechanical study

Introduction

Intramedullary nailing is the treatment of choice for most displaced tibial shaft fractures. The ability to maintain a mechanically stable fixation becomes more difficult the further the fracture extends distally or proximally or when unreamed tibial nails are used. We assumed that a new angular stable locking option would provide improved stability and reduced interfragmentary movements in a distal tibia in vitro fracture model.

Materials and methods

Left and right bones of 8 pairs of human cadaveric tibiae were randomly assigned to either a group with conventional locked or a group with angular stable locked intramedullary nails. Nails of 10-mm-diameter were used after reaming up to 11 mm. A transverse distal osteotomy was performed and the specimens were tested mechanically under eccentric axial load. A video optical measurement system was used to determine the angular displacement of the osteotomy gap during loading.

Results

Construct stiffness, maximum load of the bone-nail construct and gap angle at 0.5 kN load were measured. The group with the angular stable locking option showed significantly higher stiffness values and reduced fracture gap motion compared to the group with conventional locked nails.

Discussion

A new angular stable locking option of intramedullary nails provides higher stability in terms of construct stiffness and reduced interfragmentary movements in a distal tibia in vitro fracture model.     

Displaced humeral shaft fractures in children and adolescents: results and adverse effects in patients treated by elastic stable intramedullary nailing

Purpose

The objectives of this study were to retrospectively investigate the clinical and radiological outcome of humeral shaft fractures treated by ESIN in children <16 years old and to evaluate the functional outcome of these injuries using the short version of the Disabilities of the Arm, Shoulder and Hand Outcome questionnaire (Quick DASH^®).

Methods

We retrospectively evaluated children with fractures of the humeral shaft, surgically treated by ESIN. All the patients were regularly followed clinically and radiographically for at least 1 year after their index surgery. After hardware removal, the patients were asked to answer the short version of the Disabilities of the Arm, Shoulder and Hand Outcome questionnaire (Quick DASH).

Results

Thirty-eight patients met the inclusion criteria. Mean age at the time of trauma was 11.1 years. Mean follow-up was 30 months. All fractures healed, but three patients had a residual valgus of >10°, two a residual varum of >10°, four a residual recurvatum deformity of >10°, and one a residual procurvatum deformity of >10°. Four complications were observed. Functional outcome was nevertheless good in all the patients, with a mean Quick DASH^® score of 3.

Conclusion

The study shows good clinical and functional outcomes in children and adolescents with closed isolated fractures of the humeral shaft surgically treated by ESIN, even with ensuing mild residual frontal and sagittal plane deformity. However, conservative treatment has also been advocated in the scientific literature for this type of injuries, and surgical treatment should not be considered as the only option for the management of humeral shaft fractures in older children and adolescents.

     

Winkelstabile, mehrdimensionale Plattenosteosynthese der Klavikulaschaftfraktur

Background

The goal of this consecutive, retrospective clinical follow-up study was to analyse the quality of treatment with a multidimensional, anatomical locking plate osteosynthesis after comminuted clavicle shaft fracture (Robinson 2B).

Patients and methods

Of 38 operated patients, 35 were examined after locking plate osteosynthesis, with a median follow-up of 32 months (11–65). Four patients had suffered a 2B1 Robinson fracture and 31 patients a 2B2 Robinson fracture. The clinical and functional results were determined based on the standard clinical examination of the shoulder, the Constant and DASH scores, an analogue visual scale and a patient survey.

Results

The clinical examination yielded a mean DASH score of 1.25, a mean Constant score of 98 and a mean VAS score on the visual analogue scale of 0.4 (with a range of 0–6). Neither nonunion nor implant failure was observed. We did, however, have one case of infection of the soft tissue.

Conclusion

The treatment of comminuted shaft fractures of the clavicle by means of a multidimensional locking plate is a safe treatment option that includes early functional postoperative care with free range of motion.     

Healing process after rigid plate fixation of humeral shaft fractures revisited

Objective

The purpose of this study was to describe the radiological healing process after open reduction and internal fixation (ORIF) of humeral shaft fractures with plate.

Materials and methods

We reviewed the data of 53 consecutive patients who had undergone rigid plate fixation of OTA 12 A or B humeral shaft fracture. The mean age of the patients at the time of surgery was 39.4 (range 16–82). Quality of reduction and healing process was analysed on radiographs. Clinical symptom and disabilities of the arm, shoulder and hand (DASH) scores were recorded at follow-up visits.

Results

There were 28 compression and 25 neutralization platings. The mean gap size on the postoperative radiograph was 1.4 (range 0.1–6.1). 50 cases (94.3 %) healed, while three cases ended up with non-union. 28 (52.8 %) cases showed primary healing and 22 cases (41.5 %) showed secondary healing with callus bridging. Among the cases with secondary healing, callus formation with resorption was identified in 13 cases. The type of fracture, mode of compression and size of gap on radiographs after rigid plate fixation were found to be statistically significant factors for healing type (p = 0.026, 0.002, and <0.001, respectively). Three cases with non-union showed no improvement in DASH scores.

Conclusion

Both primary and secondary healing processes were observed after rigid plate fixation of OTA 12 A or B humeral shaft fractures. Our study revealed that size of gap, mode of compression, type of fracture could affect the type of healing, and that periosteal callus formation can occur after rigid plate fixation.     

Locked nailing with interfragmentary wiring for humeral nonunions

OBJECTIVE: Locked nailing for humeral nonunions is threatened by residual fracture gap and fracture motion. This article describes the clinical experience of using interfragmentary wiring to solve these problems. METHODS: Interfragmentary wiring was used in 21 consecutive humeral nonunions treated with humeral locked nails. The average age of patients was 49.5 years, with an average nonunion duration of 14.4 months. Eighteen patients had previous operations. Nonunions were located at the proximal third in 4, the middle third in 10, and the distal third in 7. Antegrade nailing was used in 11 and retrograde nailing in 10. Sixteen nonunions were nailed with 8-mm nails and five with 7-mm nails. Interfragmentary wiring was applied to either the posterior or the lateral cortex of humeri in a figure-of-eight configuration. Bone grafting was performed in all and average follow-up time was 22 months. RESULTS: With a single operation, all patients achieved osseous union in, on average, 18.3 weeks. One patient with segmental nonunion suffered acute renal failure 4 months after operation, but fracture healing was not affected. Wire infection occurred in one patient with preoperative infection at the nail entry site and was treated by implant removal. Other complications including two transient radial nerve palsies and one brachial artery injury did not affect the final outcome. At follow-up, all but four patients had complete recovery of shoulder flexion and abduction. The average postoperative Neer score (91.1 points) was significantly better than the average preoperative score (65.5 points). All but three patients had complete recovery of elbow motion. CONCLUSION: Interfragmentary wiring, a safe procedure if properly performed, could effectively decrease the residual fracture gap and fracture motion in locked nailing of humeral nonunions. Further biomechanical studies and prospective, randomized, controlled studies are warranted.     

Initial Surgical Treatment of Humeral Shaft Fracture Predicts Difficulty Healing when Humeral Shaft Nonunion Occurs

Background

Although most humeral nonunions are successfully treated with a single procedure, some humeral nonunions are more difficult to heal and require multiple procedures. Current literature does not provide evidence describing how the prognosis for surgical repair in patients who develop humeral diaphyseal nonunions may be affected by initial operative versus nonoperative treatment.

Questions/Purposes

The purpose of this study was to assess whether operative versus nonoperative treatment of acute humeral shaft fractures impacts outcome of subsequent repairs of humeral nonunions (NU) including the need for additional surgery and a comparison of pain relief (Visual Analogue Scale for pain) and functional outcome (Short Musculoskeletal Functional Assessment).

Methods

Thirty-four patients with humeral shaft nonunion were evaluated of which 15 patients had been treated operatively (OF), and 19 patients had been treated nonoperatively (NO) for their initial humerus shaft fracture. All patients underwent plating with autogenous bone graft or allograft ± bone morphogenic protein (BMP) 2 or 7 as their final NU repair surgery prior to healing. We compared functional outcome and pain for both cohorts and determined risk factors for requiring more than 1 nonunion repair surgery.

Results

The mean time of final follow-up was 14.7?±?10.4 months. Thirty-three of 34 NUs (97.1%) healed. Patients who underwent OF of their original fracture were more likely to require more than 1 NU repair surgery (66.7 vs. 0%, p?<?0.01). Of the 15 patients who underwent initial OF, 33.0% required 1 NU surgery, 33.0% required 2 NU surgeries, and 33.0% required 3 NU surgeries. Patients who underwent initial OF were more likely to require >6 months to achieve union (40.0 vs. 10.5%, p?=?0.04). At final follow-up, there was no difference in functional outcome or pain scores. Initial OF was the only independent predictor of needing more than 1 NU repair surgery (OR 70.1 CI 2.8–1762.3) to achieve healing.

Conclusion

Humeral shaft nonunions following initial operative fixation of the index fracture is more resistant to achieving union when compared to nonunions forming after initial nonoperative treatment. When final healing is achieved, there is no difference in function or pain.

     

Minimally invasive plate osteosynthesis for humeral shaft fracture: a reproducible technique with the assistance of an external fixator

Background

Minimally invasive plate osteosynthesis (MIPO) has become a popular option for treatment of humeral shaft fractures. However, indirect reduction might risk unpromising results, with mal-alignment/mal-union or nonunion. The purpose of this study was to describe a reproducible MIPO technique that used an external fixator during the procedure as a tool for reduction and maintenance, and to assess the outcomes in patients with humeral shaft fracture.

Methods

Of 31 consecutive cases of humeral shaft fracture in 30 patients, 29 were included in this study. There were seven simple (type A) and 22 comminuted (type B or C) fractures. After the insertion of one Schanz pin on each proximal and distal humerus, a provisional reduction was achieved by connecting the pins with a monolateral external fixator. The MIPO procedure was then performed over the anterior aspect of the humerus. To evaluate the efficacy of the provisional reduction by external fixator, coronal and sagittal alignments were assessed. We also assessed bony and functional results, including complications, from this technique.

Results

There was no case of mal-union >10°, and mean angulation was 1.3° (range 0°–9°) in the coronal plane and 1.2° (range 0°–8°) in the sagittal plane. Twenty-eight of 29 fractures were united, including three delayed unions, with a mean union time of 19.1 weeks (range 12.3–38.4 weeks) and a mean follow-up of 20.8 months (range 13.5–31.0 months). There was one hypertrophic nonunion that healed after fixing with two additional screws. Except one patient with associated injury in the elbow, all patients recovered to pre-injury joint motion. There were two cases of postoperative radial nerve palsy that both recovered completely. We attributed them to manipulation, and not to the Schanz pins or plate fixation.

Conclusions

Surgical treatment of humeral shaft fractures with external fixator-assisted reduction and MIPO resulted in excellent reductions and high union rates.

Level of Evidence

IV